Gloria Monte: Prevention of future deaths report 

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There was a delay in diagnosing Gloria’s cancer of approximately one-year.
She had attended the ED following a fall in February 2024. She was admitted to ED where a chest x-ray and trauma CT was arranged. The provisional report of the scan identified traumatic injuries and a lung nodule (14mm) which was described by the radiologist as “…likely incidental but could be a primary lung tumour”.

The radiologist did not consider that the threshold for conserus alerting (new probable cancer) was triggered.

The ED doctor noted the incidental finding and recorded the same in the records when referring the patient to Major Trauma, with the expectation that Gloria would be admitted under Major Trauma and referred to the lung nodule MDT by the admitting team.

The major trauma doctor reviewed Gloria in ED and determined that she did
not require admission. She therefore remained an ED patient and the ED team prepared her discharge summary (which mentioned the incidental nodule but again made no referral for MDT review).

The GP was not tasked with actioning a referral or follow up. The discharge summary was not shared with the patient (either in hard copy or electronically through the NHS app).

The nodule was never investigated. Various outpatient and inpatient reviews took place over the course of the year but without any speciality noting the reference to the nodule (and lack of review).

Gloria attended her GP in February 2025 with chest symptoms. She was treated with antibiotics but when she failed to improve, her GP arranged an admission to hospital. There, chest imaging showed findings suspicious of lung cancer and comparison with the February 2024 imaging led to the conclusion that the nodule noted the year prior probably was cancer.

If diagnosis had been achieved as expected in 2024, Gloria would have been counselled on the available treatment options. If she had accepted those options, it is possible that she may have lived for longer than she in fact did, but I have been unable to determine whether her life would probably have been extended because there are many variables to the success of, and side effects of, cancer treatment.

The risk of incidental imaging findings being overlooked has been known
about by NUH for years and appears on the Trust’s risk register. There has
been a long-standing failure to adequately mitigate this risk, and there is ongoing dispute about who is responsible for actioning incidental imaging findings; ED (as the investigation originator to whom the results/reports will  always be sent) or the admitting team. There is further discussion about the extent to which lung nodules fall under the consensus radiology reporting criteria for new cancer.

The MATTERS OF CONCERN are as follows:
1. A failure to have in place a clear policy identifying the clinician responsible for acknowledging and actioning incidental findings from ED imaging

This prevention of future deaths report follows the report issued at the conclusion of the inquest touching the death of David Marriott, at which similar themes were explored.

Gloria’s death is a further example of the Trust’s failure to have in place a clear policy on who holds responsibility for taking action following a report of incidental findings on imaging requested by ED teams.

During the course of this inquest, I heard evidence that a draft SOP is currently being considered which shall place responsibility not with the originator of the imaging request (to whom the report shall be sent) but with the admitting team.

I heard evidence of concerns regarding this proposed course, based on the variables that exist once a patient is referred to a speciality and/or leaves ED.
I am concerned that there is a risk of future deaths presented by the current SOP in the following scenarios:

a. A patient might be referred to a speciality by the ED doctor holding a
mindset that the patient is going to be admitted, only to find that the speciality has not admitted the patient. Where does responsibility rest then? If the speciality is being requested to provide a specialist opinion relevant to their expertise (and out of hours this is likely to be an incredibly stretched junior doctor covering the wards/theatre, as well as ED admissions and the on-call phone), is it reasonable to expect the speciality to pick up and action incidental findings arising from imaging request by ED?

b. A patient might be admitted by a speciality, only to find that they have a
more urgent medical concern which requires urgent transfer to another speciality. Where does responsibility rest then?

c. Despite referral to a speciality, the patient might self-discharge before being seen by the speciality or admitted if accepted. Where does responsibility rest then?

Ultimately, requests for investigations come with results, and those results need to be acknowledged and actioned in a timely and appropriate manner. NHSE guidance proposes that responsibility should rest with the originator. “The clinician who orders or requests the imaging test—known as the referrer—is fundamentally responsible for acknowledging, reviewing, and acting upon the results. In emergency care, when shift handovers occur or teams share workloads, the responsibility must be clearly delegated and tracked”.

It is disappointing that locally our largest Trust has no agreed SOP to address this risk when NPSAs have been issued on this topic consistently since 2007.

2. An over-reliance on consensus alerts to identify and safety net incidental findings and a lack of clarity of language in the Trust’s Radiology Guidelines

I heard evidence that there is a division of opinion amongst radiology colleagues as to whether a 14mm pulmonary nodule should trigger a cancer alert via consensus (there is agreement that it should be reported, of course).
The policy states “5.2 New cancer imaging expected or unexpected.
This includes expected or unexpected imaging findings that suggest new or probable new cancer and new or probable new cancer recurrence within the report.”

Later the policy provides a non-exhaustive list of examples, including, “An unexpected lung nodule or a solid renal mass suspicious of a new carcinoma”

There are three different standards mooted within the guidance – suspected,  probable and suspicious – which is unhelpful. Whether the threshold of  suspicious applies only to a solid renal mass is also open for debate.

In Gloria’s case, the radiologist reported the nodule as “likely incidental but  could be a primary lung tumour”. 

The British Thoracic Society Guidelines (2015) identify pulmonary nodules of  greater than 5-6mm as requiring follow up (the degree of action then increases based on size). In which case, might this be a clear trigger for an alert?

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